Magazine Article | July 5, 2012

Don't Be Ruled By Your Forms

Source: Health IT Outcomes

By Vicki Amendola, Editor, Health IT Outcomes

This NYC provider was tired of being held hostage by the costs and inefficiencies of its preprinted forms processes. A new eForms solution set them free.

Chances are that your patients spend quite a bit of time filling out forms in your hospitals and medical practices, even in the midst of the massive migration to electronic medical records. However, as innocuous or simple these forms seem, I would dare say that they remain the lifeblood of the healthcare system — gathering critical information that drives every process from patient care to healthcare administration and finance. But chances are that you’re so used to the multitude of forms that are a part of your daily routine that you’ve never really thought about the impact that paper — and preprinted forms in particular — can have on your facility. Unfavorable impacts in terms of cost, space, and even process efficiency. The Hospital for Special Surgery (HSS) did take the time to evaluate these impacts and, concerned with the realities that were discovered, pursued an eForms technology solution for relief.


Located in New York City, HSS was founded in 1863, often being ranked as a leader in orthopedics, rheumatology, and rehabilitation. Throughout its facilities, preprinted paper forms were a part of normal everyday operations. Patient registration, discharge, and transfers are all examples of areas that were tightly tied to form use. The preprinted forms served their purpose in gathering and collating information, but according to project specialist Andre M. Cascio, they also presented a few specific disadvantages.

One of the main detriments was the sheer cost of maintaining an adequate inventory of preprinted forms. In most cases, HSS was having quantities of forms printed at local retail print outlets. Closely tied to the cost of printing forms was the lack of adequate storage space. “We were constantly running out of preprinted forms and having to quickly go to the vendor and say we needed another box of this form or that form,” says Cascio. “While this practice worked, it wasn’t convenient, and it was far from inexpensive.”

Form revisions also presented a challenge to HSS. Each time a revision to a form needed to be made, HSS would have to have a new inventory of the revised forms printed and then throw away the remaining inventory of the old forms. Often revisions would occur around information that is JCAHO (Joint Commission on the Accreditation of Healthcare Organizations)-related, but it could also be something as simple as an extension number or even a sentence or single word. “If you can picture in your mind a whole room full of boxes of forms and then realize that with one small revision, you have to throw them all out,” says Cascio. “It’s not just a waste. It is actually painful when you realize the amount of money your facility just threw away when you replace those forms.”

“It’s not just a waste. It is actually painful when you realize the amount of money your facility just threw away when you replace those forms.”

Ensuring proper version control was also an area of concern with preprinted forms. Even though remaining inventories of forms were destroyed when revised forms were printed, it would be common for some old inventory to remain — tucked into files, in cabinets in nursing stations, in offices. There just wasn’t any way to be sure that all of the outdated forms were collected. Logically, there were times where the older and the newer versions of the preprinted forms would get mixed together. “You could have different departments using different versions of the same form,” says Cascio. “Looking at our forms processes gave us a heightened awareness of all of these versions that different departments are using, and luckily we didn’t have an instance where it really affected quality or patient care. It was just semantics, and we wanted to make sure that we have one current version of each form so there would be no confusion between departments and patients getting different versions.”


HSS had been meeting some of its document management needs with products from Bottomline Technologies, so it looked to the vendor again for a solution to its preprinted forms challenges. During evaluation, HSS did include two other vendors but determined that MedEx, an eForms solution from Bottomline, was the best fit to meet the hospital’s goals.

MedEx is a Web-based document automation system that enables users to access, produce, and print forms on demand, as well as to produce forms that are automatically populated with patient data. “We have this lean initiative where anything that we could do to streamline the patient process of coming in and getting registered and just moving them along,” says Cascio. “Hospitals are all about forms and more forms. To have patient data automatically populate onto these forms and easily accessible is a no-brainer. It supports our goal of making the whole patient process more efficient.”

The first phase of HSS’ eForms project launched in September 2011, primarily impacting the areas of registration and admittance, some of the nursing areas, and infusion therapy. Patient registration offers a great example of the negative impact preprinted forms could have on process efficiency.

Prior to eForms, registering a patient in the McKesson Star ADT (admission, discharge, and transfer) system caused a lot of work for the patients and a lot of work for the registrars in the form of timeconsuming chart preparation and management. Staff would spend a great deal of time pulling blank forms and creating packets of paperwork for incoming patients — the dreaded clipboard patients are faced with almost every time they come in for medical care. On top of that, staff also had to be sure that the proper packet of forms was handed to each patient, as not every packet would be the same depending on the reason the patient was coming in for care.

Now, with the MedEx solution in place, the user just needs to log in to the McKesson Star system, select the correct patient, and select the desired packet of forms. That packet could then be printed on demand, eliminating the cost of keeping an inventory of — and potentially outdated versions of — preprinted forms. Furthermore, these on-demand forms could often be autopopulated with the patient’s basic information. “It is literally a click, and ten forms will come out with all of the patient information already populated onto the forms,” says Cascio. “We have the patients review it for accuracy and sign off on anything that needs to be signed off, and you just saved a lot of time.” Not only did this save staff time, it saved the patients time, too, resulting in greater patient satisfaction.


Following its early eForms success, HSS is entering the next phase of deployment, which continues further into a more extensive list of departments including nutrition, case management, lab, rehab, OR material, prosthetics, patient education, anesthesia, and the executive offices. “Phase 2 is definitelya different game from Phase 1,” says Cascio. Not only does phase two bring many more departments and users into the system, it also brings about a significant shift in HSS’ patient identification process.

“Hospitals are all about forms and more forms. To have patient data automatically populate onto these forms and easily accessible is a no-brainer.”

HSS is doing a complete redesign of its patient wristbands which will include bar codes. “Right now we have a chaotic process where there is a mini assembly line to create a patient wristband,” says Cascio. “With this one, it is just going to print out.” HSS has selected high-volume multimedia Zebra printers, some of which will be installed right next to the desktops in use in admittance. “As patients come in, not only will they get the forms preprinted, but they will also get a wristband right there and then. They don’t have to take off the sticker and put it on a piece of cardboard. It is right there. It is printed. It is on your wrist, let’s move along,” says Cascio. HSS expects Phase 2 to be completed during the summer of 2012.


According to Cascio, one of the biggest lessons HSS has learned during its transition to eForms is the importance of having a formal forms approval process. “We found that there were different expectations across leadership regarding how forms are approved and the approval process. We didn’t really have a formal forms committee to approve changes,” reflects Cascio. “People who wanted an update would just contact the vendor themselves and say we need this updated, and the forms would be revised and reprinted.”

The adoption of eForms has enabled HSS to completely redefine the whole approval process and achieve better governance of form updates. Revisions can no longer be made “on a whim” with all changes required to go through a formal forms committee review process. Now, any department that wishes their forms to be updated or changed in any way has to go through a facilitator who presents the change request to the forms committee, which includes the director and assistant director of medical records, during a regular monthly meeting.

The committee will review the old form and the requested changes. The committee also ensures that all changes are communicated to all departments that will be impacted by the revision. Once the revisions are agreed upon, the changes are approved, signed off, and then sent to the IT department where they will do the design and upload the new form into MedEx.

Cascio states that rolling out the new eForms solution also gave HSS a heightened awareness of all of the form discrepancies within its facilities. “There were different forms going across the whole hospital, and having this solution is really eliminating that,” says Cascio. “I keep saying that because it was a huge challenge. But even though it was a challenge, it was a plus for us to make that change and redefine that process.” Staff now operates with the confidence that whatever form resides within MedEx is the correct, current version.


Of all the lessons learned, Cascio has a few to recommend to others either considering or on the path to forms automation. The first is to make sure that your project stays within scope and also to ensure than your expectations are well-documented and wellcommunicated to project sponsors. He also warns that providers should be aware that an implementation such as this is going to raise awareness of glitches and process flows. “You are going to need improvements into the workflow, and you need to be aware of that,” says Cascio. “React to the challenges you uncover as opportunities and not failures.”

Following these pointers has led to success at HSS, where Cascio says that owning the ability to revise and update forms internally has been a huge plus for the hospital. “We have definitely minimized costs of preprinted forms. We diminished chart preparation time. We freed up staff members to do other tasks because the chart completion time is literally cut in half,” says Cascio. All along this process, Cascio has measured success by the number of different departments proactively requesting to have their forms automated. “They are all coming to us because they have heard about this brand new MedEx,” says Cascio. “We are expecting even greater response when we get the wristbands going.”